The patient was admitted to the hospital on June 12, 2008, with “right proximal calf soreness and walking limitation for more than 3 months”. In March 2006, the patient began to experience soreness and occasional pain in the proximal calf with no obvious cause, and the soreness and swelling were persistent and worsened with increased activity. On June 8, 2006, after walking about 500 m during daily walking, he felt weakness and unbearable pain in his right proximal calf and could not walk, and intermittent claudication occurred. He was treated with “Fotarine 25mg, 3 times/day” at the local hospital, and did not improve after taking it for nearly two weeks. At the same time, a “jujube” sized swelling was found below the knee joint, which was painful to palpation. He visited a local hospital and underwent X-ray examination, which indicated a proximal tibial swelling, and came to our hospital for further treatment. There was no history of trauma or infection in the past. Physical examination: T 36.5℃, P 75/min, R 18/min, BP 125/80mmHg, clear respiratory sounds in both lungs, no dry and humid fermium fermium murshanshen耄囊粲辛Γ次偶霸右簟S掖笸绕し粑薹⒑猜鑫耷牛植课奘质 Rah: 奂榜嫉蚁溃蚁ス亟谥芪Ъ∪Naan尬酢S倚⊥冉饲胺娇杉宦∑鹬孜铮笮≡1.0cm*1.0cm, the skin temperature is not high when touched. The texture was soft, the mobility was poor, and the demarcation with the surrounding tissues was not clear. The right foot had normal sensation and blood flow, and the right dorsalis pedis artery was pulsating normally. Laboratory tests did not show any significant abnormalities. X-ray examination of the tibia by Liu Zhao, Department of Orthopedics, Xuanwu Hospital, Capital Medical University, showed multiple small foci of fusion in the proximal tibia with osteolytic changes and clear borders with the surrounding bone. Enhanced CT of the tibia showed that the proximal tibia was significantly strengthened within the bone destruction area with clear borders, and no significant abnormalities were seen in the surrounding soft tissues. On June 18, 2008, the right proximal tibia was scraped under endotracheal anesthesia, and an osteotomy and internal fixation was performed with an autologous iliac bone graft. Pathological findings: a mixture of bone tissue, osteoid tissue and new bone, rich in vascular supporting tissue. Osteoblasts were predominant, actively proliferating and closely arranged in a vascular-rich stroma, and the diagnosis was osteoid osteoma. On review more than one year after surgery, X-ray examination was performed, suggesting: local osteolytic changes, unhealed bone, and tumor recurrence. CT of the tibia suggested that the bone was not healed and no continuous bone trabeculae passed locally. On 2010-7-6, the endophyte removal + tumor enlargement resection + distal tibial osteotomy + external fixation frame was performed under intravertebral anesthesia. On September 29, 2010, he underwent external fixation brace adjustment under local anesthesia and general analgesia because of inversion deformity of the right foot at 2 months after the operation. He is now recovering well after surgery. Discussion of the attending physician: The patient is a middle-aged female with a slow progression of disease. The main symptoms were soreness and limitation of walking in the proximal right calf. The patient’s condition was delayed due to her own reasons. The diagnosis of this patient initially relied on imaging. X-ray of the tibia suggested multiple small foci of fusion in the proximal tibia with osteolytic changes and clear borders with the surrounding bone. Enhanced CT of the tibia suggested that the area of bone destruction in the proximal tibia was significantly enhanced with clear borders, and no significant abnormalities were seen in the surrounding soft tissues. According to the patient’s clinical performance, physical signs and imaging examination, it was suggested that the mass was benign. The age of onset of osteoid osteoma is most common between 10 and 30 years old, but it can also be seen in infants under 1 year old or in elderly people over 60 years old. It is more common in males than females, with an incidence rate of 2:1. The incidence rate in the lower extremities is about three times that of the upper extremities, and is less common in the trunk bones. The tibia and femur are the most common, accounting for about half of the cases. This is followed by the fibula, humerus and spine. The treatment option for this benign tumor is lesion scraping + autologous iliac bone harvesting (and/or allograft bone) implantation + internal fixation. Primary care physician: Osteoid osteoma is a benign osteogenic tumor consisting of osteoblasts and the bone-like tissue they produce. It accounts for approximately 1% of all bone tumors and 10% of benign bone tumors. The lesion is a small nest of tumor surrounded by many mature reactive bones. The course of the disease is characteristic, with the pain appearing early, often months before the positive lesion appears on the radiograph. At the beginning of the disease, the pain is intermittent and worsens at night. At a later stage, the pain is more severe and persistent, and it is difficult for the usual pain medications to be effective. The pain is mostly limited and the soft tissues may be swollen, but the affected area is minimal. In addition to X-ray examination, CT examination of tibia is also an important examination method, which can help physicians to understand the scope of tumor and surrounding soft tissues. Puncture needle biopsy to take specimens for pathological biopsy is the gold standard to diagnose the nature of the mass. However, this patient is considered to be a benign tumor, and the significance of performing puncture biopsy is not significant because the treatment plan for benign tumor is lesion removal + bone grafting internal fixation. Associate Chief Physician: Agree with the above two physicians. This patient needs to be staged after the diagnosis is clear in order to guide the treatment. Currently, the staging system of the International Society of Skeletal Muscular System Oncology is used for bone tumors, which basically consists of the following three aspects: pathological grading (G), interstitial (T) and distant metastasis (M). Based on laboratory tests and imaging, and the fact that benign tumors generally do not metastasize, this patient was staged as G0T0M0. However, one year after the first surgery, the patient developed a local tumor recurrence with bone cortical discontinuity. The most important issue for the patient now is: to eradicate the tumor completely and strive for no recurrence after surgery. Therefore, the only more fundamental approach was an extended tumor resection. At the same time, another problem arises: how to compensate for the huge bone defect. If the fibula with vascular tip is taken, its support is not good; if the bone is taken from autologous iliac bone + allograft bone, delayed bone healing and dead bone formation and bone non-healing will be a big problem. The problem that needs to be dealt with urgently is how to compensate for the bone defect created by the huge tibial resection. Chief Physician: The advent of the Ilizaron Bone Fixator provides a powerful tool for the treatment of large bone defects. By osteotomy of the tibial epiphysis, the fracture end is gradually retracted towards the defect area, eventually filling the bone defect. During the pulling process, it is important to note that due to the relative change in the position of the starting point of some muscles that control the movement of the limb at this time, flexion contracture deformity of the end of the limb occurs, etc. During the treatment process, the patient is encouraged to walk with appropriate portion of weight bearing to stimulate the formation of bone scabs in the fracture and defect area. At the same time, functional exercises of the affected limb should be enhanced to prevent a series of problems brought about by long-term fixation. Postscript: According to WHO statistics, osteoid osteoma accounts for 5.10% of primary bone tumors and 11.23% of benign bone tumors. Postoperative X-ray review is also necessary. Recurrence is rare after complete resection of the lesion, while incomplete scraping often results in recurrence. The length of recurrence varies. For larger portions of bone defects, the Ilizaron technique has been a boon to patients, but attention is paid to the complications of the use of the Ilizaron technique. Address for correspondence: 45 Changchun Street, Xicheng District, Beijing 100053, China Tel: 010-83198899 ext. 8641 E-mail: [email protected]附图片: [email protected]附图片: Figure 1: Preoperative X-ray Figure 2: Pictures after initial surgery Figure 3 Postoperative recurrence Figure 4 Ilizarov technique Treatment of large tibial defect